1. Field of the Invention
The present invention generally relates to methods of assessment and negotiation of insurance claims. Certain embodiments relate to systems and methods of evaluating the effectiveness and consistency of computer processes and systems used in insurance assessment and negotiation.
2. Description of the Related Art
Insurance companies have been processing and settling claims associated with bodily injury for a long time. The task of evaluating, analyzing or estimating the amount of damage associated with one or more types of bodily injuries, especially trauma-induced bodily injuries, can be very complex. Complexity in the evaluation process often arises out of the fact that concurrent expertise in legal, medical and insurance fields is often required to arrive at a particular decision involving a bodily injury claim.
Several factors can affect the estimated amount of the claim associated with a bodily injury. Every accident is different and every injury is unique. Arriving at a customized evaluation of a bodily injury claim, which is unique for a specific accident, injury, etc. is desirable. Applying across-the-board standards may tend to result in an inequitable solution for one or more parties involved. External environmental factors, such as the experience level of a claims adjuster, record of accomplishment of the legal professionals, post-injury quality of life for the injured party, etc., all may affect the valuation of a claim.
Many insurance companies have been using computer-based and knowledge-based claim-processing systems to process, evaluate, analyze and estimate thousands or even millions of claims in what is intended to be a fair and consistent manner. A knowledge-based claim-processing system may include an expert system which utilizes and builds a knowledge base to assist the user in decision making. Such a system may allow the insurance companies to define new business rules and/or use previously defined rules, in real-time. The business rules are generally written by industry experts to evaluate legal, medical, insurance conditions before arriving at a valuation of a claim.
The use of assessment tools can improve the fairness and equity in claim adjusting, especially the equity between claimants with similar claims. However, there is often significant variation in the values of similar claims. In many instances, these variations may be warranted by the individual nuances of a particular claim. However, there are also a number of claims with widely disparate values that likely have no real material differences to warrant these disparate values. For any given insurer, there may be a number of precedent claims in the insurer's closed claim database that embody the best practices for a particular candidate claim; however, finding and presenting these claims to the insurer's claim team as a basis for closing the candidate claim may not be possible due to the sheer size of the database and the difficulty in matching the essential features of a claim with the available tools or methods.
Even where assessment tools for claims adjustment and negotiation are being used (or considered for use) by an organization, it may be difficult to assess how useful or consistent the values (e.g., dollar amounts) being generated using the system are.